Jun 06, 2022

The CMS National Quality Strategy: A Person-Centered Approach to Improving Quality

Michelle Schreiber, M.D.; Adam C. Richards, MA; Jean Moody-Williams, RN, MPP; Lee A. Fleisher, M.D.
Topic

The Centers for Medicare & Medicaid Services (CMS) administers health care coverage for more than 150 million individuals through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Marketplace – HealthCare.gov. The vision of the agency is straightforward: To serve the public as a trusted partner and steward, dedicated to advancing health equity, expanding access to affordable coverage and care, and improving health outcomes – the latter being key to this discussion. In addition to its traditional role in coverage, CMS has a critically important responsibility for improving health outcomes, and one aspect of that work is quality.

In order to achieve optimal health and well-being for all Americans, it is essential to have a high quality, safe, equitable, and resilient health care system – one that is built on a foundation of dedicated physicians, clinicians, staff, patients, families and other caregivers. However, even before the COVID-19 pandemic, our quality of care continued to rank lowest on many measures of care among all industrialized nations, despite higher national spending 1] The onset of COVID-19 illuminated, and in certain cases exacerbated, the acute need to develop novel solutions to improve the quality of care for all Americans, especially members of underserved and under-resourced communities. Taken together, these aspects drive the need for continued progress on quality within the health care system.

Improving quality and outcomes is certainly not a new concept to CMS. In fact, the agency has advanced previous quality strategies, focusing on making care safer, increasing engagement, promoting effective prevention and treatment of chronic disease, and making quality measurement meaningful and transparent to providers, individuals, and their families. Additionally, CMS establishes health and safety standards through Conditions for Coverage and Conditions of Participation (the rules for health care providers to participate in the Medicare and Medicaid programs), manages a variety of quality reporting and value-based purchasing programs, runs the largest value-based program—the Medicare Shared Savings Program—in the country, drives transparency through public tools such as Care Compare, and strategically uses the Quality Improvement Organizations, which are health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare. These efforts have proven successful. One example is the CMS-led Partnership for Patients, in which multiple federal agencies, hospitals, clinicians, and patients joined together to achieve a 13% reduction in hospital-acquired conditions from 2014-2017 according to the Agency for Healthcare Research and Quality National Scorecard.  This resulted in saving about 20,700 lives and about $7.7 billion in healthcare costs.[2]

While these are important achievements, in many cases they have not been sustained or been inclusive of underserved communities.[3] CMS recognizes the evolving nature of the United States health care system and advances in technology, measurement science, quality improvement approaches, and the many opportunities for improvement that remain.

Driving Improvements in Quality 

Given the urgent need for action within the health care system and the lessons learned during the pandemic, CMS is taking an aggressive step forward as a national voice for quality. On April 12, 2022, the agency launched the CMS National Quality Strategy, an ambitious long-term initiative that aims to promote the highest quality outcomes and safest care for all individuals.[4]  

The CMS National Quality Strategy focuses on a person-centric approach from birth to death as individuals journey across the continuum of care, from home or community-based settings to hospital to post-acute care, and across payer types, including Traditional Medicare, Medicare Advantage, Medicaid and Children’s Health Insurance Program coverage, and Marketplace plans. It builds on our previous efforts to improve quality across the health care system, incorporates lessons learned from the COVID-19 Public Health Emergency (PHE), and endeavors to foster and promote the expanded levers used during the pandemic such as interoperability and data sharing, data collection specific to social determinants of health and social risk factors, telehealth, emergency preparedness, leadership, and organizational governance among others. The CMS National Quality Strategy also embraces the anticipated acceleration of consumer demand for data and information to make informed care decisions. Overall, the CMS National Quality Strategy will help create a more equitable, safe, and outcomes-based health care system for all individuals.

In developing the CMS National Quality Strategy, it was important to us to ensure alignment to other key agency initiatives, such as our strategies for behavioral health, value, and health equity.[5],[6]

Quality is integral to value, which is the highest quality care the most affordable cost. So, critical elements such as safety, person-centered care, integration of physical and behavioral health, and equity are all foundational components not only of quality, but of value as well. Quality, including driving better health outcomes, will be an essential part of value and deeply embedded in CMS policies and programs. The CMS National Quality Strategy will support the agency’s approach to value by increasing alignment across the quality reporting and value-based payment programs, accelerating the path toward value, and addressing upstream drivers of health.

Importantly, true quality cannot exist without equity. The CMS National Quality Strategy directly supports agency efforts to ensure equitable access, quality, and outcomes for all individuals CMS serves, including members of racial and ethnic minority communities, people with disabilities, members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community, individuals with limited English proficiency, members of rural communities, and people otherwise adversely affected by persistent poverty or inequality.

The CMS National Quality Strategy at a Glance

The CMS National Quality Strategy consists of eight core goals. These goals add the next layer of depth to the broader strategic vision for quality within health care that is built upon a culture of quality and safety at every level.

Goal 1: Embed Quality into the Care Journey

Making quality a core part of the care journey is a critical element of the CMS National Quality Strategy as it seeks to establish quality as a foundational component to delivering value across an individual’s overall care journey. Quality includes, but is not limited to, ensuring optimal care and best outcomes for individuals of all ages and backgrounds as well as across service delivery systems and settings, including preventive, acute, chronic, and long-term care with a focus on health-related social needs. Quality also extends across payer types, such as Traditional Medicare, Medicare Advantage, Medicaid (fee-for-service and managed care) and CHIP, and Marketplace plans.

This is an important goal because the health care system is complex and often poses unique challenges to all individuals at some point along their care journey. Creating a smoother journey by taking a person-centered approach across an individual’s lifespan (focusing on combining physical and behavioral health with health-related social needs), addressing access and barriers, including the individual’s voice, and resolving gaps in care is critical in helping individuals achieve the best possible outcomes. 

Goal 2: Advance Health Equity

CMS defines health equity as the attainment of the highest levels of health for all people so that every person has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.[7] This goal seeks to address the disparities and injustices that underlie and permeate our health system, both within and across settings, to ensure equitable access and care for all. The COVID-19 PHE highlighted many of the stark inequities that exist within our health care system. CMS’s goal is to advance progress in creating a care journey that is free from inequity while optimizing opportunities, access, and outcomes for historically underserved and under-resourced communities.

Goal 3: Promote Safety

This is a bold goal that strives to prevent all harm or death from health care errors. Health care errors remain a significant source of injury and death, and this has worsened during the COVID-19 PHE. Serious safety events are rarely the result of one individual error; rather, they are typically the result of several system flaws. CMS aims to ensure that measures, quality improvement, payment, and certification programs assess, and hold accountable, health care systems and providers to keep individuals safe. Additionally, CMS strongly supports a culture of safety as a foundational element to ensuring the best care for all individuals. This form of culture includes deeply embedded safety processes, leadership and governance commitments, and strategic oversight for prevention.

Goal 4: Foster Engagement

CMS has focused significant attention on increasing engagement among providers, individuals, and their families to promote informed and collaborative decision-making. All individuals, their families, providers, and other caregivers should have the opportunity to engage in open discussions to promote shared decision making as well as build trust. To promote this aim, CMS’s goal is to ensure that all individuals, their families, their caregivers, and even payers have access to understandable and meaningful health care data, which includes preferences and health-related social needs, and individual care plans drafted in a culturally and linguistically appropriate manner that will assist them in making informed care decisions. CMS expects health care providers to use the data and information in a proactive way to discuss care options with individuals, their families, and the communities in which they live and work. It is also critical to ensure the voice of the individual is included in care decisions and that directly reported feedback regarding facility, provider, or payer performance is incorporated as a part of a comprehensive approach to quality. Additionally, actively engaging with federal entities, external stakeholders, the states and territories, communities, and others ensures diverse perspectives regarding quality, outcomes, and performance are considered.

Goal 5: Strengthen Resiliency

The COVID-19 PHE unveiled opportunities to improve major aspects of the health care system, such as coordination, operations (including addressing workforce shortages), and preparedness. In collaboration with federal partners and external stakeholders, using lessons learned, it is important to develop metrics, quality assurance and improvement programs, conditions of participation, and other actions that evaluate and promote the ability of health care systems and providers to be prepared for a changing health care ecosystem and be able to flexibly adapt to future emergencies or challenges.

CMS also believes that it is important to define what resiliency means to providers, from physicians to nurses to medical assistants, to promote sustainable cultural change across the health care system that embraces individual values and empowers all staff to deliver quality care.

Goal 6: Embrace the Digital Age

Electronic data, which is standardized, shared, and able to communicate with other systems (interoperable), is essential to promote seamless care coordination and communication. Interoperable digital health data also supports continuous learning health care systems and ensures individuals have access to their information to support informed decision-making as well as referrals and community planning. The vision for this body of work under the CMS National Quality Strategy is to ensure timely, secure, seamless communication and care coordination between providers, plans, payers, community organizations, and patients through interoperable, shared, and standardized digital data across the care continuum to achieve desired outcomes and provide patients direct access to their information. Additionally, CMS commits to fully transitioning to digital quality measurement as a part of the long-term strategy to improve payer-provider alignment and give people access to their health data when and where it is needed.

Goal 7: Incentivize Innovation and Technology Adoption to Drive Care Improvements

Continuous innovation and change will help lead health care transformation. CMS must ensure that scientific evidence and data from all populations the agency serves, including members of historically underserved and under-resourced communities, is used to drive decisions. Additionally, evidence and data should support new payments and policies as well as inform new quality improvement interventions and educational outreach to help advance these innovations.

Goal 8: Increasing Alignment

This is one area where CMS continues to receive significant feedback. Current programs, performance metrics, and policies can sometimes be confusing or burdensome, and we realize this can be compounded by needless duplication or lack of alignment. Too often the number of programs and requirements along with different payment approaches inadvertently become impediments to care, especially when they remain unaligned. CMS will endeavor to develop a seamless, coordinated, and transparent approach to align performance metrics, quality improvement efforts, programs, policy, and payment across CMS, federal affiliates, states and territories, and the private sector to improve value. The agency will also strive to create a simplified national picture of quality measurement that is comprehensible to individuals, their families, providers, and payers. Importantly, while stronger alignment will promote transparency and burden reduction, it also helps CMS facilitate the most impactful and consistent advances in health equity across all programs and the communities we serve.

Next Steps

The launch of the CMS National Quality Strategy and discussion of the overall vision for quality is the first phase in our new multi-part approach. The next and arguably most important phase is implementation. This is where the proverbial rubber meets the road – where CMS, in collaboration with stakeholders, develops and operationalizes both short and long-term actions to drive forward the goals of the CMS National Quality Strategy. Continuous engagement is pivotal, and CMS will begin listening sessions in early summer 2022.

Additionally, the agency will look to federal affiliates, external stakeholders, Quality Improvement Organizations, private payers, states and territories, and others to implement the goals outlined in the CMS National Quality Strategy. The success of this strategy relies on coordination, innovative thinking, and collaboration across all entities. A unified approach brings everyone one step closer to the health care system envisioned for every individual.

Now is the time to act. If the COVID-19 pandemic taught anything, it is that no action is too small to improve the overall quality and safety for every individual seeking care. CMS accepts the challenge to drive quality forward over the next decade and looks forward to working with all interested stakeholders to improve the United States health care system.

Acknowledgements

The authors wish to acknowledge Dr. LaShawn McIver, Director of the CMS Office of Minority Health and Executive Co-sponsor of the CMS National Quality Strategy, Dr. Douglas Jacobs, Chief Transformation Officer in the Center for Medicare, as well as all of the members of the new CMS Quality Workgroup for their support and dedication in helping to shape and implement the CMS National Quality Strategy for the betterment of all individuals. Thank you!

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[1] Roosa Tikkanen and Melinda K. Abrams, U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes? (Commonwealth Fund, January 2020). https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019. Accessed on March 31, 2022.

[2] Agency for Healthcare Research and Quality (AHRQ) Scorecard on Hospital-Acquired Conditions Final Results for 2014-2017. (Agency for Healthcare Research and Quality, July 2020). https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf. Accessed on April 25, 2022.

[3] Lee Fleisher and Michelle Schreiber, Health Care Safety during the Pandemic and Beyond – Building a System That Ensures Resiliency. (New England Journal of Medicine – Perspective, February 2022). https://www.nejm.org/doi/full/10.1056/NEJMp2118285. Accessed on April 25, 2022.

[4] CMS National Quality Strategy. (Centers for Medicare & Medicaid Services, April 2022). https://www.cms.gov/files/document/cms-national-quality-strategy-fact-sheet-april-2022.pdf. Accessed on May 24, 2022.

[5] CMS Behavioral Health Strategy. (Centers for Medicare & Medicaid Services, April 2022). https://www.cms.gov/sites/default/files/2022-04/CCI%20Fact%20Sheet%20Behavioral%20Health-4132002-clean-508.pdf. Accessed on April 27, 2022.

[6] CMS Framework for Health Equity 2022-2032. (Centers for Medicare & Medicaid Services, April 2022). https://www.cms.gov/sites/default/files/2022-04/CMS%20Framework%20for%20Health%20Equity_2022%2004%2006.pdf. Accessed on April 25, 2022.

[7] CMS Framework for Health Equity 2022-2032. (Centers for Medicare & Medicaid Services, April 2022). https://www.cms.gov/sites/default/files/2022-04/CMS%20Framework%20for%20Health%20Equity_2022%2004%2006.pdf. Accessed on April 25, 2022.